Medical Records Transfer Request Form
Patient's Name Date of Birth
Patient's Name Date of Birth
Patient's Name Date of Birth
Patient's Name Date of Birth
Current Address (Street, City, State, Zip Code):
Current Telephone Number:
Parent's Email Address:

TRANSFEREE / TO:
Name of New Doctor/Institution and Telephone Number


TRANSFEREE ADDRESS:
City, State, Zip Code

Records will be mailed to the new doctor or Institution unless otherwise stated by the parent.


Please tell us your reason for requesting records and/or reason for leaving our practice

 


I understand that this consent can be revoked at any time except to the extent that disclosure made in good faith has already occurred in reliance on this consent. The facility, its employees, officers and attending physicians are released from legal responsibility or liability for the release of the above information to the extent indicated and authorized herein.

Parent's Name



Security code:



There is a fee for all requests to transfer medical records out. The fee must be paid prior to the picking up or mailing out of records.

There will be a charge of $20 per patient for copying records.